Healthcare Provider Details

I. General information

NPI: 1932640356
Provider Name (Legal Business Name): TED ANDREW SPIEWAK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 07/21/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

673 MDG 5955 ZEAMER AVE
JBER AK
99506
US

IV. Provider business mailing address

673 MDG 5955 ZEAMER AVE
JBER AK
99506
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-2632
  • Fax:
Mailing address:
  • Phone: 907-580-2632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number16961
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: